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UNDEOGROUND STORAGE TANK #STEM OWNER STATEMENTS OF DESIGNATED UST OPERAT UNDERSTANDING OF AND COMPLIANCE WITH UST REQ -4"ED For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited. Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) JAN 2 7 2011 FACILITY NAME Ryder Truck Rental #1071 4FACILITY PHONE (209) 943-3213 ENVIRONMENTAL HEALTH FACILITY SITE ADDRESS PERMIT/SERVICES 3633 Duck Creek Drive Tv Stockton REASON FOR SUBMITTING THIS FORM(Check One): ® Change of Designated Operator P Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Elmer Mortera RELATION TO UST FACILITY(Check One) BUSINESS NAME Qfdierentfrom above): Balch Petroleum DESIGNATED OPERATOR PHONE: 1:1 Owner 11 Operator ElEmployee (408) 942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 524HO5Z-UC EXPIRATION DATE: ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(O tion[) 4/2/2011 DESIGNATED OPERATOR NAME: Ryan Lipert RELATION TO UST FACILITY(Check One) BUSINESS NAME viaWerentjrom above): Balch Petroleum DESIGNATED OPERATOR PHONE: ❑ Owner [I Operator EJ Employee (408) 942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5295268-UC EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACH ITY(Opt[onaq 10/22/2012 DESIGNATED OPERATOR NAME: ROlan(t0 Urbina RELATION TO UST FACILITY(Check One) BUSINESS NAME(/fdj7erentfrom above): Balch Petroleum DESIGNATED OPERATOR PHONE: ❑ Owner El Operator ❑ Employee (408) 942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8009631-UC EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) 10/22/2012 DESIGNATED OPERATOR NAME: RELATION TO UST FACI BUSINESS NAME(IfdiJJerentjrom above): LITY(Check One) DESIGNATED OPERATOR PHONE: ( ) ❑ Owner ❑ Operator ❑ Employee ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations, Title 23, Section 2715(c) through (1). Furthermore, I understand and am in compliance with the requirements(statutes, regulations, and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Corey McMillan TANK OWNER TITLE: Compliance Manager OWNER PHONE (281) 647-8900 TANK OWNER SIGNATURE: DATE: January 25 2011 INSTRUCTIONS 1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: www.iccSafe.org/e/certsearch.html. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at:www.Swreb.ca.gov/cWphOme/uSt/contacts/docs/lOcal_agency_list.xls. 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-1/1 www.wiidoes.org 09/22/05